Aneurysms Surgery - Presentation, Investigation & Therapy Flashcards
What does aneurysm of the aorta involve?
Dilatation of all layers of the aorta, leading to an increase in diameter of >50% (abdominal aorta >3cm)
What are the following branches of the aorta?
What are the causes of aneurysm disease?
- Degenerative disease
- Connective tissue disease (e.g. Marfan’s disease)
- Infection (mycotic aneurysm)
What are the risk factors for degenerative AAA disease?
Male sex
Age
Smoking
Hypertension
Family History
What level does the abdominal aorta bifurcate?
L4
What do you use to feel the AAA?
Two hands - pulsating
At what age in England are men invited for AAA screening?
65
What is presentation of AAA?
Asymptomatic
What is the criteria for screening?
Definable disease (can’t be vague)
Prevalence (must have a considerable prevalence)
Severity of disease (no point screening for the common cold)
Natural history
Reliable detection
Early detection confers advantage
Treatment options available (needs to have a possible plan to treat once found)
Cost
Feasibility
Acceptability
What are the outcomes for screening?
A) Normal aorta, discharged
B) Small AAA (3.0-4.4cm) will be invited for annual USS scans
C) Medium AAA (4.5-5.5cm) will be invited for 3 monthly USS scans
D) Large AAA (>5.5cm)
What are the symptoms of an impending rupture?
Increasing back pain
Aorta tender to examine
Inflammation seen on CT
Tender AAA
What are the symptoms of rupture?
Abdo/back/flank pain
Painful pulsatile mass
Haemodynamic instability (single episode or progressive)
Hypoperfusion
What are unusual presentations of abdominal aortic aneuryism?
Distal embolisation - blood flow through aortic sac has a lot of thrombus (Rupture thromboses and can embolise to other parts of the body)
Aortocaval fistula – aneurysm erodes into the wall of the vena cava. aortic blood circulates to venous system without perfusing the limbs – perfuses into the vena cava
Aortoenteric fistula - erodes into the bowel - bleeding into usually the duodenum
Ureteric occlusion
Duodenal obstruction
What is management of asymptomatic patients?
Is the aneurysm a size to consider repair?
Is the patient a candidate for repair?
Is the aneurysm suitable for endovascular repair?
At what level of aneurysm size does surgery stop confering benefit?
For aneurysms less than 5.5 cm
How do you assess patient fitness?
Full history and examination
Bloods
ECG
ECHO
PFTs (pulmonary function tests)
MPS (myocardial perfusion scans)
CPEX (cardiopulmonary exercise testing)
End of the bed test?
Patient preference
What are the two methods of aneurysm repair?
Endovascular (keyhole or open repair)
What are the benefits and disadvantages of ultrasound scanning
Benefits:
- No radiation
- No contrast
- Cheap
Disadvantages:
- Operator dependent
- Inadequate for surgical planning
What are the benefits and disadvantages of CT/MRA
Advantages
Quick
Not operator dependent
Necessary for surgical planning – detailed anatomy
Disadvantages:
Contrast
Radiation
Which type of operating procedure has a higher risk of rupture?
Open repair is less than 6%
Endovascular repair is less than 1%
What are the complications of open repair?
General:
- Wound infection / dehiscence
- Bleeding
- Pain
- Scar
Technical:
- Damage to bowel, ureters, veins, nerves
- Incisional hernia
- Graft infection
- Distal emboli
- Renal failure
- Colonic ischaemia
Patient Factors:
- DVT/PE
- MI
- Stroke
- Death
What are the endovascular repair complications?
- General:
- Wound infection
- Bleeding / haematoma
- Pain
- Scar
- Contrast – reaction / kidney injury
- Radiation
Technical
- Endoleak
- Femoral artery dissection / pseudoaneurysm
- Rupture
- Distal emboli / ischaemia / colonic ischaemia
- Damage to femoral vein / nerve
Patient factors:
- DVT/PE
- MI
- Stroke
- Death
What is an endoleak?
When the blood travels into the aneurysm sack instead of the inserted tube
What is management of symptomatic AAA?
ABCDE
History, check records
Examination - of pulsatile mass in adomen
CTA - if considering treatment
What are the key features of an emergency open repair of AAA?
Massive transfusion protocol – need blood because of leak
Prep abdomen, rapid anaesthetic (Patient needs to be kept away to keep them using the abdominal muscles provides tamponade to bleeding)
Laparotomy xiphisternum to pubic symphysis
Occlude aorta proximally
30-50% mortality, significant morbidity
Why don’t we always use endovascular repair?
Relying on the radial force holding the grafts in place in the diseased aorta AAA is a degenerative disease, over time the aneuryism progresses and causes endoleaks. Needs ongoing surveillance and scans and maybe intervention in the future. Increased costs. Longer term mortality is similar between both methods. For those who were not fit for operation, there is no advantage giving them an endovascular repair.
What is a risk of emergency EVAR?
Abdominal compartment syndrome – no removal of blood from abdomen. Too musch pressure in the abdomen – kidney failure.
Is there any benefit for EVAR or open repair in the case of ruptured AAA?
No difference in the end for all cause mortality - any form of repair will result in health complications becasue of severity of the damage.
